Zorgtoeslag voor mensen met lage inkomens heeft bewezen extreem duur te zijn.
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In 2006 heeft Nederland een gemandateerd particuliere verzekering systeem ingevoerd vergelijkbaar met Zwitserland Onder deze hervorming, zijn alle legale inwoners van Nederland verplicht om de basisverzekering te kopen van particuliere verzekeraars. De zorgplicht zorgde voor sterk gereguleerd zorg. Ze kunnen aanvragers niet weigeren, ongeacht de gezondheidstoestand, zo blijkt uit een casestudy in het NEJM.
In 2011, verzekeringspremies kostte toen gemiddeld ongeveer € 1.200 ($ 1.749) per persoon, met een verplicht eigen risico van € 170 ($ 248). Werknemers moeten bovendien bijdragen via de loonbelasting voor de ziektekostenverzekering – 7,75% van hun loon, tot een maximum van € 2.590 (3.774 dollar). Voorstanders van dit systeem voerde aan dat de concurrentie tussen particuliere verzekeraars ervoor zouden gaan zorgen dat de uitgaven voor gezondheidszorg verminderden, de keuze van de consument zou verbeteren, en de verbetering van de kwaliteit van de zorg en de gezondheidszorg zou beter worden. De realiteit van gereguleerde concurrentie in Nederland laat zien dat dit anno 2012 niet zo werkt.
Vier belangrijke elementen zijn naar voren gekomen van het Nederlandse systeem. Ten eerste is de concurrentie niet scherp en dat vertraagde de groei van de uitgaven voor gezondheidszorg. Zorguitgaven blijven de algemene inflatie overtreffen, met een stijging van gemiddeld 5% per jaar sinds 2006. De totale kosten van de ziektekostenverzekering voor Nederlandse gezinnen, met inbegrip van premies en eigen risico’s, steeg met 41%. Volgens het CBS in 2010, besteedde Nederland besteedde 14,8% van zijn bruto binnenlands product uit aan zorg en welzijn (met inbegrip van langdurige zorg en andere sociale diensten).
Hervormingen die gericht zijn op het vergroten van en het beheren van concurrentie zorgden alleen maar voor hoge administratieve kosten en meer complexiteit. De zorgtoeslag voor mensen met lage inkomens heeft bewezen extreem duur te zijn. Meer dan 40% van de Nederlandse gezinnen ontvangt dergelijke een zorgtoeslag – en de fiscus heeft meer dan 600 extra medewerkers ingehuurd om de inkomens te controleren en elke maand en de waarde van de zorgtoeslag te berekenen.
Het aantal onverzekerden is weliswaar gedaald sinds 2006, van ongeveer 240.000 tot 150.000. Maar een groeiend aantal “wanbetalers” -Â is in 2010 gestegen naar 319.000. De toename van de wanbetalers (die samen met de onverzekerde, bedraagt ongeveer 3% van de bevolking).
In 2006 is ongeveer 18% van de Nederlanders overgestapt verzekeringen. Maar het volgende jaar minder dan 5%, en 80% van hen deed dat als gevolg van de wijzigingen die door hun werkgevers werden doorgevoerd in plaats van op basis van individuele beslissingen. We hebben nu vier verzekerings conglomeraten in het land en die controleren ongeveer 90% van de Nederlandse markt voor ziektekostenverzekeringen. Recente peilingen laten publieke ontevredenheid met particuliere verzekeraars zien, 65% van de verzekerden heeft nog vertrouwen in hun verzekeraar.
De Nederlandse zorg steunt nog steeds sterk op de regelgeving. Sterker nog, de Nederlandse casus laat zien dat concurrerende systemen wat het zoel was van de hervormingen slechts geleid heeft naar een bureaucratische controle van de medische zorg. De regering heeft geen afstand gedaan van haar traditionele instrumenten, waaronder mondiale budgetten en beperkingen op de prijzen en de patient verdeling van de kosten. Het zet vergoedingen voor onafhankelijke specialisten en huisartsen onder druk. De betalingen aan specialisten werden verlaagd in reactie op budgetoverschrijdingen.
Dat concurrentie is de sleutel is om de zorgkosten in te perken is een illusie. De Nederlandse laat zien dat particuliere verzekeringen niet bijdragen aan concurrentie en hervorming van de gezondheidszorg.
Managed Competition for Medicare? Sobering Lessons from
the Netherlands
Kieke G.H. Okma, Ph.D., Theodore R. Marmor, Ph.D., and Jonathan Oberlander, Ph.D.
N Engl J Med 2011; 365:287-289July 28, 2011
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- Citing Articles (4)
Discussions about U.S. health care reform are often parochial, with scant attention paid to other countries’ experiences. It is thus surprising that in the ongoing debate over Medicare, some U.S. commentators have turned to the Netherlands as a model of regulated competition among private insurance companies.1 The Dutch experience is particularly relevant given the proposal by Congressman Paul Ryan (R-WI) to eliminate traditional Medicare and instead provide beneficiaries with vouchers to purchase private insurance. (The Republican majority in the House passed the Ryan plan as part of the 2012 budget resolution, but it was defeated in the Senate.)
It is easy to understand why Dutch health care — which does rely on regulated private insurance — would appeal to advocates of Medicare vouchers. Indeed, U.S. ideas about managed competition helped to shape health care reform in the Netherlands.2 But careful examination of the Dutch experience shows that insurance competition has not produced the expected benefits and in fact has created new problems, calling into question the merits of this reform model and its suitability for Medicare.
Before 2006, the Netherlands had a mixed health insurance system, with more than 60% of the population covered by mandatory social insurance, administered by nonprofit sick funds. The remaining population had private insurance, voluntarily purchased, and the uninsured rate was about 1.5%.
In 2006, the Netherlands replaced this arrangement with a mandated private insurance system similar to Switzerland’s.3 Under this reform, all legal residents of the Netherlands are required to purchase basic insurance from private insurers. Private plans are heavily regulated. They cannot turn down applicants, regardless of health status, and must charge community-rated premiums. A risk-equalization scheme varies payment to health plans according to their enrolled populations’ risk profiles. The aim is to reduce plans’ incentives to select profitable patients and ensure that plans with sicker, higher-cost populations are not financially penalized. Insurance plans are expected to compete on the basis of price and quality by selectively contracting with networks of hospitals, physicians, and other medical care providers.
In 2011, insurance premiums averaged about €1,200 ($1,749) per person, with a mandatory deductible of €170 ($248). Workers must additionally contribute earmarked payroll taxes for health insurance — 7.75% of their wages, up to a maximum of €2,590 ($3,774). General taxes also help to fund government health care expenditures, including paying all premium costs for children under the age of 18 years. A separate insurance program, requiring another 12% payroll tax, finances long-term care. Supplemental coverage for services such as dental care and physical therapy is purchased by about 90% of persons with basic insurance.
Advocates of this system argued that competition among private insurers would reduce health care spending, enhance consumer choice, and improve the quality of care and the health system’s responsiveness to patients — arguments that are being repeated in the U.S. debate over Medicare. The reality of managed competition in the Netherlands, however, has not matched the rhetoric.3
Four key points emerge from the Dutch experience. First, competition has not sharply slowed the rate of growth in health care spending. Health care expenditures continue to outpace general inflation, having increased at an average annual rate of 5% since 2006. At the same time, the total costs of health insurance for Dutch families, including premiums and deductibles, increased by 41%. According to Statistics Netherlands, in 2010 the country spent 14.8% of its gross domestic product on health care and welfare (including long-term care and other social services).
Reforms aimed at increasing and managing competition also produced high administrative costs and complexity. Administering premium subsidies for low-income people has proven expensive. More than 40% of Dutch families now receive such subsidies — and the national tax department hired more than 600 extra staff members to check incomes each month and calculate the value of the vouchers.
Second, some Dutch people remain uninsured, and there has been a substantial increase in the number of insured persons failing to pay their insurance premiums. The number of uninsured people has decreased since 2006, from about 240,000 to 150,000. But a growing number of “defaulters†— 319,000 in 2010 — haven’t paid their insurance premiums for more than 6 months. Insurers can legally terminate their coverage. The increase in defaulters (who, together with the uninsured, account for about 3% of the population) has embarrassed the Dutch government. Policymakers have responded by pressuring insurers not to drop them and by covering missing payments with public funds. A 2011 law gives the government the authority to garnish delinquent workers’ wages to pay for insurance premiums (they are also subject to a premium fine).
Third, the expansion of consumer choice has not worked as envisioned. In 2006, about 18% of Dutch people switched insurance plans. But the following year less than 5% switched, and 80% of them did so as a result of changes made by their employers rather than individual decisions. Since 2007, only about 4% of the Dutch population, on average, has changed plans each year. Moreover, accelerating consolidation of the health insurance market has restricted meaningful choice of insurance plan. Currently, four insurance conglomerates control about 90% of the Dutch health insurance market. Recent polls suggest public dissatisfaction with private insurers, with 65% of insured people reporting that they have low or very low levels of trust in private plans.
Fourth, notwithstanding the rhetoric of competition, the Netherlands still relies heavily on regulation. Indeed, the Dutch case shows that competitive systems that seek to escape supposedly centralized, bureaucratic control of medical care paradoxically require sophisticated regulation and government intervention in order to work. The government has not abandoned its traditional tools, including global budgets and constraints on prices and patient cost sharing. It sets fees for independent specialists and general practitioners and controls prices for most hospital services.4 In 2010, for example, payments to specialists were reduced in response to budget overruns.
The Dutch Ministry of Health regularly engages in talks with the health insurance industry when there are complaints about rising premiums or copayments. Insurers must offer comprehensive coverage, and direct payments by patients amount to less than 10% of total medical care costs, among the lowest percentages in industrialized countries. The comprehensiveness of health insurance in the Netherlands provides a critical contrast to the Ryan Medicare plan, which would erode the U.S. government’s contribution to the point that 65-year-old beneficiaries would pay about two thirds of medical costs themselves.
The myth that competition has been key to cost containment in the Netherlands has obscured a crucial reality. Health care systems in Europe, Canada, Japan, and beyond, all of which spend much less than the United States on medical services, rely on regulation of prices, coordinated payment, budgets, and in some cases limits on selected expensive medical technologies, to contain health care spending.5 Systemwide regulation of spending, rather than competition among insurers, is the key to controlling health care costs. The Netherlands, after all, spent much less on medical care than the United States with virtually universal insurance coverage long before it began experimenting with managed competition in 2006.
The Dutch experience provides a cautionary tale about the place of private insurance competition in health care reform. The Dutch reforms have fallen far short of expectations — a reminder that policy intentions should not be confused with outcomes and that managed competition is hardly a panacea. The idea that the Dutch reforms provide a successful model for U.S. Medicare to emulate is bizarre. The Dutch case in fact underscores the pitfalls of the casual use (and misuse) of international experience in U.S. health care reform debates.5 Before we learn from other countries’ experiences with medical care, we first need to learn about them.
Disclosure forms provided by the authors are available with the full text of this article at NEJM.org.
This article (10.1056/NEJMp1106090) was published on June 15, 2011, at NEJM.org.
Source Information
From New York University, New York (K.G.H.O.); Yale University, New Haven, CT (T.R.M.); and the University of North Carolina, Chapel Hill (J.O.).
Bron: NEJM (met dank aan @csidokter voor de tip)
